Provider Demographics
NPI:1841904307
Name:WILLARD, AUSTIN (SOIDC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:WILLARD
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D MARINE RAIDER BATTALION
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0073
Mailing Address - Country:US
Mailing Address - Phone:910-440-1947
Mailing Address - Fax:
Practice Address - Street 1:3D MARINE RAIDER BATTALION
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0073
Practice Address - Country:US
Practice Address - Phone:910-440-1947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Single Specialty